Internal Medicine Questionnaire New Consult

Internal Medicine Questionnaire

**New Consult**
Dear Pet Parent:

Some of the questions may seem unrelated to your pet's current situation but all the little details help me see the big picture and provide the very best recommendations. Thank you in advance for sharing this information and helping me help you and your pet!

Sincerely,

Dr. Hammer
Your pet's name*
Pet parent's name*

First NameLast Name
What is {yourPets}'s birthday? (current age if you are not sure {yourPets}'s of exact birthday)*
When did you adopt {yourPets}?*
Sex*
Sex - other: explain below
Age at which {yourPets} was neutered if known
Breed*
If unsure or not purebred, note type of mix if you know (e.g. Lab mix, Terrier mix etc.)

Clinical Signs at Home

This section will review everything you are seeing at home. Some may not apply to your pet. Those that do, the more detail the better. Colors, frequency, time of day, left or right side....anything you can think of.
How is your {yourPets}'s appetite/ interest in food?*
Describe (note any changes related to medications, etc)
How are {yourPets}'s bowel movements?*
If abnormal describe further including color, consistency, frequency, larger or smaller amounts than normal, mucus, blood, straining etc.
Here is a helpful link with descriptions and grading schemes for bowel movements in cats and dogs. Purina Fecal Scoring Link....
Is {yourPets} vomiting or regurgitating?*
Vomiting involves an active abdominal component (heaving, retching). Regurgitation is often passive where food or liquid appears to just 'fall' out {yourPets}'s mouth.
If abnormal describe further including frequency, relation to eating, vomiting versus regurgitation, changes with diet or medication etc.
How is {yourPets}'s weight?*
If there have been weight changes, describe further including relationship to diet changes, medications, changes in appetite etc.
How is your {yourPets}'s thirst?*
If abnormal, describe further (note any changes related to diet, medications tried etc.)
How is your {yourPets}'s urination?*
If abnormal, describe further including changes in color, larger or smaller volumes, frequency, accidents in the house, leaking, changes related to medications or diet etc.
Is {yourPets} coughing or having other respiratory signs?*
If yes, describe further...Coughing more while sleeping versus when more active/ excited? How does it sound? Is the cough productive? Heavy breathing or excessive panting? Tiring out quicker? Changes with any medications?
Does {yourPets} have sneezing or nasal discharge?*
If yes, describe further....what does the discharge look like (bloody, mucus etc). Left, right or both nostrils? Frequency of sneezing? After sleeping? More outside etc?
How is {yourPets}'s activity level and behavior?*
Please describe.

{yourPets}'s Previous Medical History
Has {yourPets} had any previous illnesses or surgeries? Please describe below.*

Current Medications *

	Name of Medication	Dose (e.g. mg, units etc.)	Route (e.g. oral, topical etc)	Frequency (how many times per day)
1
2
3
4
5
6
7
8

Do you feel that any of these medications have helped {yourPets}'s signs? Are there any side effects and are they impacting {yourPets}'s or your quality of life? Any difficulties administering (liquids versus tablets?)?*
Is {yourPets} on heartworm/flea/tick preventive?*
Names of preventives?
If {yourPets} is a cat, has {yourPets} been tested for FeLV/FIV?
Do you know when the last time {yourPets} was tested and what the results were?

Environmental/ General Management Questions

These are general questions about general care, household and environment.
What is {yourPets} currently eating? If this is not {yourPets}'s normal diet, what is {yourPets}'s normal or previous diet? Please include amount fed and how many times per day. Treats? Food preferences (canned? dry? people food? etc.)?*
Does {yourPets} have housemates?*
Who are {yourPets}'s housemates? Any other details that may be significant such as medical problems, interactions with {yourPets}, etc.
What is {yourPets}'s environment?*
Describe further if needed
Does {yourPets} have any travel history outside of this region (recent or prior to adoption?)*
Describe further if needed
Does {yourPets} have any exposure to toxins or medications not prescribed specifically for {yourPets}?*
Describe

You are almost done!!
Is there anything that I did not ask that you would like to share about {yourPets}? Please feel free to upload pictures or videos that you think may be helpful.
File Upload

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If you would like a copy of your finished consult, please provide your e-mail address below.
example@example.com
You and your veterinarian have requested this consult and thus have provided their records to me to review. If there are any other records from other veterinarians including previous veterinarians, second opinions, specialty or emergency visits, please upload them below or have them e-mailed directly to me (kim@hammer.vet). The more information I have, the better consult I can provide.

Keep in mind that the majority of communications will take place through your primary veterinarian. At this time, I am not able to manage patients primarily but my goal is always to provide the best care for you and your pet.
Should be Empty:

Internal Medicine Questionnaire

Clinical Signs at Home

{yourPets}'s Previous Medical History

Environmental/ General Management Questions

You are almost done!!